Nursing home blaze which killed

Sheriff Principal Brian Lockhart, in his fatal accident inquiry report, said: The management of fire safety at Rosepark was systematically and seriously defective.

These deficiencies in the management of fire safety at Rosepark contributed to the deaths in that Justin Houston Jersey Authentic a number of key circumstances would have been quite different if there had been an adequate system of fire safety management.

Similarly, bedroom doors should have been fitted with devices to shut them in the event of fire as this would have made a significant difference to residents' survival chances.

There were too many people sleeping in one corridor to allow for an effective evacuation and this passageway should have been split in half.

This would have allowed staff to realise the extent of the fire and pass this information to firefighters.

But staff had no idea how to interpret fire alarm information and advised the fire brigade both in the initial call and subsequently the fire kicked off in the wrong place.

Sheriff Lockhart said: Had Isobel Queen been able to accurately identify at the outset the location of the alarm which had activated she would even applying the inadequate procedure which pertained at the home have immediately sent two members of staff to investigate that area.

He added: Management did not recognise an important change in the fire safety arrangements namely the new fire alarm panel required to be reflected in the instruction of relevant staff.

It can at least be said that the conduct of the fire services might have been different in a manner which could have expedited the rescue of those residents who were still alive.

There was a window of opportunity, (albeit a short one), during which prompt emergency fire fighting by the staff on duty might have extinguished the fire.

This window of opportunity lasted for about two to five minutes from the sounding of the alarm.

It would have taken staff less than 30 seconds at a run to reach cupboard A2 from the fire alarm panel.

There were fire extinguishers located en route which staff could have picked up on the way and properly trained staff would be expected to do that.

None of the staff on duty had received fire response training apart from three, Ms Queen, Irene Richmond and Yvonne Carlisle, who had once been shown a video.

There was a nine minute delay between the fire alarm sounding and the fire service being contacted and a further four minute delay because the postal address given to them was not the homes entrance.

When they did arrive, the fire service failed to independently check the information given to them by nursing home staff regarding the location of the blaze.

A proper fire risk asssessment a statutory requirement for care homes had not been carried out.

Such a document should identify worst case scenarios, including night fires, means of escape and emergency

procedures for staff to follow.

Sheriff Lockhart also blasted the way boss Thomas Balmer managed the homes construction.

He said: While he had some experience of managing construction projects, he had no experience of managing a project which involved structural fire precautions of the sort required at Rosepark.

He also slammed NHS Lanarkshires inspectors.

He said: The regime of inspection was not advised by any clear determination by the health board of what standards of fire precautions it considered to be sufficient.

He added: The defects in the systems of work of Lanarkshire Health Board contributed to some or all of the deaths.